Healthcare Provider Details

I. General information

NPI: 1609114883
Provider Name (Legal Business Name): CORNELIUS COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2013
Last Update Date: 01/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 SILVER LAKE RD NW
NEW BRIGHTON MN
55112-9301
US

IV. Provider business mailing address

1405 SILVER LAKE RD NW
NEW BRIGHTON MN
55112-9301
US

V. Phone/Fax

Practice location:
  • Phone: 651-895-3624
  • Fax:
Mailing address:
  • Phone: 651-895-3624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC00430
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberCC0430
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberCC0430
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC00430
License Number StateMN

VIII. Authorized Official

Name: AMANDA V CORNELIUS
Title or Position: OWNER
Credential: LPCC
Phone: 651-895-3624